The main findings of our study were that greater reported dietary sodium intake was independently associated with an increased risk of all-cause mortality and modestly increased ultrafiltration requirements.

Were any of the findings unexpected?

We did not find a consistent significant association between dietary sodium intake and pre-dialysis systolic blood pressure, nor did we find a significant association between prescribed restrictions of dietary sodium (>2g vs ≤2g/day) and mortality.

Previous studies of hemodialysis patients have described reductions in blood pressure with dietary sodium restriction, but usually in the context of simultaneous changes in dialysate sodium, or ultrafiltration and dry weight reduction.

The difference in reported dietary sodium intake between those prescribed a restriction of >2g/day compared to ≤2g/day was only 200mg; this speaks to a lack of compliance with dietary restrictions and may partly explain why we did not find an association between prescribed restriction and mortality. This may also temper enthusiasm for targeting dietary sodium intake (at least via current methods) as a means to improve patient outcomes.

What should clinicians and patients take away from this study?

The results of this study are intriguing and provide supportive evidence of an association between increased dietary sodium intake and all-cause mortality in chronic hemodialysis patients.

That the mortality relationship effect estimates were accentuated upon adjustment for nutritional parameters suggests that any benefits of dietary sodium restriction may be countered by unintentional nutritional compromise.

Therefore, any interventions aimed at dietary sodium reduction that are motivated by these findings should consider the need to preserve total caloric intake.

What recommendations do you have for future studies as a result of your study?

This study provides rationale for greater emphasis on the dietary advice we dispense to our patients; while dietary sodium restriction should be encouraged, great care must be taken to avoid unintentional restriction of global macronutrients.

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